Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 18

Download a blank fillable Form Cms-855a - Medicare Enrollment Application - Institutional Providers in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Cms-855a - Medicare Enrollment Application - Institutional Providers with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

SECTION 3: FINAL ADVERSE ACTIONS/CONVICTIONS
(Continued)
FINAL ADVERSE LEGAL HISTORY
1. Has your organization, under any current or former name or business identity, ever had a final
adverse action listed on page 16 of this application imposed against it?
YES–Continue Below
NO–Skip to Section 4
2. If yes, report each final adverse action, when it occurred, the Federal or State agency or the
court/administrative body that imposed the action, and the resolution, if any.
Attach a copy of the final adverse action documentation and resolution.
FINAL ADVERSE LEGAL ACTION
DATE
TAkEN BY
RESOLUTION
CMS-855A (07/11)
17

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Form Cms-855r - Medicare Enrollment Application - Reassignment Of Medicare Benefits Form Cms-855r - Medicare Enrollment Application - Reassignment Of Medicare Benefits Medical
Form Cms-8550 - Medicare Enrollment Application Form Cms-8550 - Medicare Enrollment Application Medical
Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers Medical
Form Cms-855i - Medicare Enrollment Application - Physicians And Non-physician Practitioners Form Cms-855i - Medicare Enrollment Application - Physicians And Non-physician Practitioners Medical
Form Cms-855s - Medicare Enrollment Application - Durable Medical Equipment, Prosthetics, Orthotics, And Supplies (dmepos) Suppliers Form Cms-855s - Medicare Enrollment Application - Durable Medical Equipment, Prosthetics, Orthotics, And Supplies (dmepos) Suppliers Medical
Form Cms-20027 - Medicare Redetermination Request Form, Form Cms-20034 - Request For Medicare Hearing By An Administrative Law Judge Etc. Form Cms-20027 - Medicare Redetermination Request Form, Form Cms-20034 - Request For Medicare Hearing By An Administrative Law Judge Etc. Medical
Form Cms-671 - Ltc Facility Application For Medicare/medicaid Form Cms-671 - Ltc Facility Application For Medicare/medicaid Medical
Form Cms-10069 - Medicare Waiver Demonstration Application Form Cms-10069 - Medicare Waiver Demonstration Application Medical
Medicare Enrolment Application Form Medicare Enrolment Application Form Medical
Form Cms-838 Medicare Credit Balance Report Certification Page Form Cms-838 Medicare Credit Balance Report Certification Page Medical

Related Categories

Parent category: Medical
Download
Go
Page of 54